In the last thirty years, medicine has adopted the widespread use of simulation for the exercise of psychomotor skills, but the best bet is cognitive training. Simulation-based learning curves improve the results of traditional didactics. In fact, you can practice as much as you want and learn from errors without consequences. The electronic platforms of clinical cases and virtual patients are the best assets to face this challenge.

Madrid – May 23, 2018. Since the Institute of Medicine in 1999 estimated that between 44,000 and 98,000 deaths occur each year in the United States due to medical errors, patient safety has occupied the clinical practice agenda. This alarming information was amplified by numbers unveiled by John Hopkins University in 2016: between 210,000 and 400,000 hospital deaths were estimated to occur due to this cause. Moreover, studies based on autopsies and negligence claims have revealed diagnostic errors in at least twenty percent of the cases, of which up to eight percent were fatal. Given these statistics, simulation emerges as a valuable tool for the achievement of higher competence levels and safer care.

Although the clinical encounter with the patient continues to be the cornerstone for the implementation of clinical reasoning, it is clear that the daily experience is insufficient. In fact, the American National Academy of Sciences estimates that 10-15% of all clinical encounters involve diagnostic errors. This compels physicians to refine their ability to collect, analyze, and synthesize data. Training based on simulation allows errors to be carried to their ultimate consequences without real repercussions, and students to receive feedback and reflect on their actions. Case simulations improve reasoning skills through repeated exposure, and the shift from static formats to the digital domain increases accessibility and makes learning more active and durable.
 
Although technology is unable to provide a shortcut for clinical excellence, it paves the way for one to build knowledge and develop skills and abilities that lead to optimal clinical performance. Several studies have documented the effective transfer of training through simulation to patient care settings. Barsuk and his colleagues from the Feinberg School of Medicine at Northwestern University in Chicago (USA) showed in 2009 that residents who dominate central venous catheter insertion in a simulation laboratory had fewer complications in an intensive care unit. In the area of obstetrics in 2006, Draycott et al., from the Department of Gynecology at the Southmead Hospital in Bristol (UK), observed improvements in neonatal outcomes of births complicated by shoulder dystocia after simulation training. Within the surgical field, those who train with simulators are faster, more precise, and make fewer mistakes during their first real case.

Simulation, which can be traced back to John Lundy's anatomy lab in the early 20th century, is a technique to replace or extend real patient experiences that evokes or reproduces interactively substantial aspects of the real world. It is an immersive and experiential opportunity. In this sense, virtual patients offer the opportunity to recreate clinical scenarios in a standardized, reproducible, and objective environment. The bulk of the pedagogical value of these patients lies in the improvement of clinical reasoning skills. Virtual patients urge to transform abstract knowledge into tacit knowledge through an active resolution of problems, while digital cases transform the clinician from a passive reader into a first-line professional whose experience and expertise are reinforced.   

Benefits and principles 
The medical profession demands from physicians to maintain and improve their skills, but continuing education activities are not usually associated with practice changes. Rarely these educational programs or methodologies have been able to demonstrate a tangible improvement in clinical practice or transferring of learning to clinical settings. Simulation, on the other hand, does that. The benefits of simulation include the possibility of standardizing and repeating content, the opportunity for interactive learning in a clinical scenario free of real risk, and the ability to design specific clinical experiences. The deliberate practice, teaching and evaluation of non-technical skills, and the possibility of replicating reality constitute the three axes on which simulation is based.

Deliberate practice pursues skills acquisition, maintenance, and continuous improvement. It is considered a more consistent predictor of success than experience or academic aptitude. It consists of analyzing strengths and weaknesses, correcting what we are doing wrong, and looking for indicators that allow us to improve even what we already do well. Hence, it is especially useful for education on technical skills, but also for reflection. On the other hand, non-technical skills put the focus on teamwork. It is a basic principle to explore communication, decision making, judgment, and leadership, which has been applied in the ICU and the delivery room, for example. The National Academy of Medicine of the United States recommends interprofessional health education as a decisive strategy for patient safety. And, finally, the possibility of placing the professional in a context faithful to reality results in an integral refinement of future interaction.   

Specifically, the published cases emulate the diagnostic process of physicians. The coupling of clinical problems and their solutions offers professionals the opportunity to update and reinforce their disease scripts (structured knowledge of a disease) and mind-sets to address common problems. The more physicians put these networks of knowledge into practice, the better their approach to future cases of real patients. It is the process that encourages learning. That is, case-based simulations improve reasoning skills by increasing the number of practice episodes. If an outpatient day is similar to this cognitive exercise, then analyzing digital cases is like getting some extra knowledge pills at the end of the day.

References

Manesh R, Dhaliwalal G. Digital Tools to Enhance Clinical Reasoning. Medical Clinics. 2015; Volume 102 (3): 559 - 565. doi:10.1016/j.mcna.2017.12.015

Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289: 2849-2856. doi:10.1001/jama.289.21.2849  

Burden A, White Pukenas E. Use of Simulation in Performance Improvement. Anesthesiology Clinics.  2017; Volume 36 (I1): 63 - 74. doi: 10.1016/j.anclin.2017.10.001